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Abstract: Austerity across Africa has been operationalized through World Bank and IMF structural adjustment programs since the 1980s, later rebranded euphemistically as poverty reduction strategies in the late 1990s. Austerity's constraints on public spending led donors to a "civil society" focus in which NGOs would fill gaps in basic social services created by public sector contraction. One consequence was large-scale redirection of growing foreign aid flows away from public services to international NGOs. Austerity in Africa coincides with the emergence of what some anthropologists call "audit cultures" among donors. Extraordinary data collection infrastructures are demanded from recipient organizations in the name of transparency. However, the Mozambique experience described here reveals that these intensive audit cultures serve to obscure the destructive effects of NGO proliferation on public health systems.
Keywords: audit culture, health systems, Mozambique, NGOs, privatization, structural adjustment
The reliance on metrics and evaluation in global health is not in itself new. Public health has long been defi ned as primarily a quantitative discipline dominated by biostatistics and epidemiology that constitute its core disciplines. However, the past two decades in global health have witnessed an increased emphasis on massive data extraction and big data modeling of public health challenges, projects, and progress. In one major instance, the Bill & Melinda Gates Foundation financed the creation of the Institute for Health Metrics and Evaluation in Seattle with $100 million to produce data on the "global burden of disease" using the disabilityadjusted life year (DALY) as its key measure (Murray et al. 2013). The increasing focus on big data collection and metrics parallels the rise of a range of concepts and terms imported from the private sector in public health such as "cost effectiveness," "return on investment," "business model," "results-based management," and "performance-based fi nancing," among others that have been integrated into the global health lexicon.
The heightened emphasis on massive data collection began to dominate global health practice nearly three decades ago and coincides with the publication of the World Bank's Investing in Health treatise in 1993 that rolled out the use of the DALY and the concept of "cost effectiveness" while making the case for privatization of health care and imposition of user fees in the developing world (WB 1993). The report signaled the...